Peptide May Help Predict Heart Diseases. Two articles appear in today's NEJM which further our knowledge of B-natriuretic peptide as a diagnostic and prognostic blood test. My experience thus far (our VA starting doing them a few months ago) agrees with these articles. BNP is now part of my diagnostic and prognostic toolbox.

One of the studies, conducted at University Hospital in Basel, Switzerland, found that measuring the peptide's levels in ER patients with shortness of breath helped doctors more quickly decide whether patients had heart failure.

That, in turn, reduced treatment costs and hospital stays by about one-fourth and lowered the percentage of patients hospitalized. The peptide test costs about $35.

The other study found that people with high levels of the peptide are three times as likely to develop heart failure within five years.

That study, funded mostly by the National Heart, Lung, and Blood Institute, examined 3,346 people. All of them are part of the Framingham Heart Study, which since 1948 has followed three generations and thousands of residents of the Boston suburb with regular physicals and tests.

``It's a continuing success story for the biomarkers, and I believe they hold real promise for the future, both for the management of patients with urgent symptoms and for preventive strategies,'' said former American Heart Association President Dr. Sidney Smith.

Smith said the findings should be considered when U.S. guidelines for diagnosing heart failure in ER patients are updated over the next year; European guidelines already call for the use of the test.

However, Smith said is too early to advocate widespread use of the test to predict heart trouble and plan preventive treatment.

Doctors believe a gradually failing heart tries to protect itself by secreting more and more of the peptide, which dilates blood vessels and lowers blood pressure.

Very interesting report - Institute of Medicine Advises on Water, Salt, Potassium Intake. The short summary: drink fluids moderately, water is no better than other fluids, eat less salt, eat more potassium containing foods.

New H.I.V. Test Identifies Cases in College Students

This is a sad and tragic story. The new HIV test, which diagnoses infection soon after exposure is very interesting.

WHO Issues Guidelines on Herbal Medicines

The U.N. health agency on Tuesday issued advice to governments around the world on how to ensure that the $60 billion herbal medicine business is safe and sustainable.

``There is a huge increase in this market. Many people are paying a lot for traditional medicines, and some insurance systems have started to reimburse (for) traditional remedies,'' said Dr. Hans Hogerzeil, acting direction of essential drugs and medicine for the World Health Organization.

``At the same time, this is an area where it is sometimes difficult to regulate properly and get safety assurance for patients.''

Medicines derived from plants, such as ginseng and echinacea, are becoming increasingly popular in rich countries and continue to be widely used in the developing world.

But the increase in popularity has been accompanied by an increase in the number of reported cases of damage to health from use of herbal medicines.

One cause is incorrect identification of plants. In the United States in 1997, people suffered serious heart problems after digitalis was accidentally substituted for plantain in dietary supplements. Fourteen cases of poisoning also have been reported in Hong Kong where the wrong root was used to produce an antiviral medicine.

Other problems include the use of poor quality plants, poor collection practices and the adding of other medications -- such as steroids -- to herbal remedies.

This is a huge problem. When will our Congress step up to the plate?

Letters to the Editor - Feb. 16, 2004

Drop current medical tort system in favor of arbitration boards
Recently I spent two weeks in a courtroom, and the two months prior in preparation for that appearance. Going to the courthouse every day, I was comforted, in an uncomfortable way, at the sight of other physicians. I nervously joked that it was like attending grand rounds. They, too, were there for malpractice cases.

After an emotionally arduous two weeks, the jury returned a verdict in my favor. The system seemed to work in the end, but I submit that it failed miserably for letting my case go as far as it did.

And

Absurd tort system pushes physicians to countersue

Regarding "Ob-gyn sues W.Va. trial lawyers" (AMNews, Jan. 26): While I agree that it seems reasonable to give lawyers a taste of their own medicine, unfortunately it degrades physicians by forcing us into playing their game.

However, until realistic reforms occur in this country (which take lawyers and juries out of the picture), countersuits appear to be the only way to bring attention to the absurdity of our medical tort system.

As Howard Beale said in Network - I'm mad as hell, and I'm not going to take it anymore. And that is how we physicians feel. We are tired of the absurdity of the current tort system.

Lawyers who play the liability lottery must be stopped

A small subset of the legal profession makes fortunes for themselves -- and creates costs for the rest of us -- by suing physicians. Whether it is justified or warranted is, for them, beside the point. It is an abuse of the legal system -- and it affects everyone.

This abuse is in the form of disingenuous lawsuits aimed at getting money from someone else -- instead of seeking compensation for someone with legitimate claims. Some might call it legalized extortion.

These abuses are choking the health care system. They are sending medical liability insurance premiums soaring for thousands of physicians, making it impractical, or impossible, for them to practice in many parts of the country.

These lawsuits lead to other agonies as well. For a physician, a wrongful suit can cause great harm -- embarrassment, loss of time, defense costs, injury to reputation and resulting loss of practice, stress and anxiety.

Meanwhile, cases with merit can take years to navigate an overloaded, confusing court system -- as they wait their day in court behind a traffic jam of frivolous suits -- brought by lawyers looking to win a litigation lottery -- and then taking a huge chunk of the award.

Authoritative studies have shown that awards do not correlate with negligence and noneconomic damages can't be objectively predicted. This creates an unstable environment akin to a chain reaction.

The trial lawyers who file the suits that breed this chaos operate in a system that imposes neither accountability nor restraint. The law puts up major obstacles to countersuits, and statutes that authorize sanctions for lawyers are rarely applied in medical liability cases.

More than 125,000 cases against physicians clog our nation's courts on any given day. Yet 70% of cases filed are closed with no payment -- and physicians win 80% of the cases that do go to trial.

Imagine the outcry if a physician had a record like that. As a surgeon, if 70% of the appendices I removed were normal, I would not be allowed to operate. Which is why I believe the medical community can agree that the time is right for a little peer review for the lawyers who file these worthless complaints.

We must fight back. We must oppose these lottery lawyers at every step. They are a curse to public health!

Readers know my feelings about our current tort situation. Ohio physicians are fighting fire with fire - Ohio physicians fight back: Panel documents frivolous lawsuits

Wanted: Blatant examples of frivolous medical malpractice lawsuits filed against Ohio physicians.

Reward: A chance to recover the money spent defending the lawsuit and put lawyers on notice that physicians are going to stand up to meritless suits.

"We are looking to find the most egregious cases to bring forth as test cases in the court and shed light on the issue," said Almeta E. Cooper, the Ohio State Medical Assn.'s general counsel.

OSMA hopes that its newly formed Frivolous Lawsuit Committee will give Ohio lawyers a disincentive to file baseless cases. The committee is believed to be the first of its kind formed by a state medical association.

OSMA is responding to an increasing number of physician members concerned that they are being named in "shotgun" lawsuits that include every physician listed on a chart. They also know of a few instances in which physicians were included even when their names weren't in the chart.

Frivolous suits are a common complaint among doctors nationwide. Physicians and insurers say these cases are contributing to rising medical liability insurance costs that are forcing doctors to retire early, discontinue high-risk services or move to states that have enacted tort reform.

They point out that it still costs insurance companies thousands of dollars to defend lawsuits that are eventually dismissed.

"More than the money, physicians have to shut down their offices to defend the suits, and it's an emotional strain," said Findlay, Ohio, internist William Kose, MD, who has a law degree and is serving on the Frivolous Lawsuit Committee. "Physicians take lawsuits personally. Someone is telling them they did not do their job properly."

But few physicians have challenged lawyers, and the success rate among physicians who have is small. OSMA hopes to change that.

Here is one blogging doc who is rooting for OSMA.

Our frequent commentor, Bernie, often causes controversy. I am delighted with controversy. Often I just ignore his arguments, but today I will share some of comments and give me interpretation.

I'm trying as hard as I can to empathize with your depiction of the current malpractice crisis. Certainly there are undesirable consequences that flow from the current litigious atmosphere. But I can't see how extra and possibly unneccesary medical tests or higher insurance bills for a well renumerated profession constitutes a crisis.

If you asked me what the health care crisis is, it's how the cost of medical care rises year after year faster than the cost of living and how little effort goes into fighting iatrogenic illness, which now constitutes our worst public health problem.

Bernie - please show some consistency. The malpractice crisis helps cause the financial crisis. It contributes to the increasing cost of health care. Those unnecessary tests cost money. And their results often lead to more tests - and yes iatrogenic illness.

Sometimes doing an extra test leads to more testing and those tests can cause complications.

Physicians are generally scared to discuss errors as they worry about liability. Everyone tries to avoid being sued.

The malpractice crisis paralyzes change. Until we modify our tort system, we will not have the resources or energy to address iatrogenic disease.

You also overhype this problem. It pales next to self-inflicted disease.

And another great non sequitor from Bernie:

I'm looking forward to seeing Tagamet ads that proclaim it causes impotence.

An for as the dangers of supplements: perhaps you can enlighten me and name a supplement that kills more people annually than aspirin or acetaminophen. I think I'll go make myself a cup of herbal tea -- I like to live dangerously.

What a wonderful lack of connection! We have no idea what the danger of supplements is - because we have no required testing in the USA. That is the problem! We know the risks of prescribed drugs. We have reporting mechanisms, and physicians are alert to new dangers. With the supplement industry we have 2 problems: inadequate testing prior to selling supplements and inadequate standardization of ingredients. Without these two necessities, why would someone ingest these so-called remedies.

I drink herbal tea - for the taste. I do not take supplements from health food stores, because they just might hurt me. I want data that they help and do not hurt. I want to know that if a patient is taking a supplement - I can look up the ingredients and understand what he/she is taking. I want to understand how the supplements might interact with medications that I prescribe. I do not think that my desires to help the patient should be trumped by a dangerous law. Patients need to know what they are taking. Is that such an unreasonable request?

Frist Expects Congress to Try to Expand Health Coverage

Dr. Frist, a principal architect of the new law to provide prescription drug benefits to the elderly, accused Democrats of waging "huge campaigns to discredit" the law. He expressed concern that their criticism might sway voters.

"Democrats right now are out banging this thing and using very partisan criticism, trying to tear it down, because they see that it is a huge leap forward," Dr. Frist said.

Mr. Bush takes credit for adding drug benefits to Medicare, a goal that long eluded Democrats. But Democrats are determined to turn the issue to their advantage by highlighting what they see as defects in the law.

"This is an opportunity for Democrats, but they must seize it and work to define the terms of the debate," says a memorandum for Congressional Democrats by Al Quinlan, president of Greenberg Quinlan Rosner Research, a political consulting concern. "It is critical to engage aggressively and not allow Bush and the Republicans to shape the dialogue."

To win the debate, the memorandum said, Democrats should "define the current law as unacceptable, not as something that can be fixed." Though "voters start with a slight inclination to support the law," it continued, they swing decisively against it when they are told that Medicare beneficiaries will face high out-of-pocket costs, high drug prices and gaps in coverage.

I worry that the politics of health care will undermine real progress. The Democrats do not seem to care whether this law helps some patients. They will not admit that having a drug benefit, even with some gaps, trumps having no drug benefit.

They see any law purely for its political ramifications. But then the Republicans are no different here. Politics trumps the common good at all times. In years past, the Congress and Senate understood compromise. The two parties worked together to at least try to craft positive legislation.

The Medicare bill is not perfect. But then neither am I, or you. Frist is right that we should watch what happens for a year or two prior to making more radical change (because this law is radical change).